ENTITLEMENT TO MEDICAL BENEFITS: applicant fails to show that disputed treatment plans are reasonable or necessary;

The applicant was injured in car accident on November 30, 2012 and sought benefits from Allstate But when the claim was denied and mediation failed, the applicant applied to the LAT for arbitration.

Issues:

A medical benefit of $2,378.58 for psychological services in a treatment and assessment plan dated September 24, 2014;

A medical benefit in the amount of $11,132.99, less $8,411.85 approved by Allstate, for psychological services in a treatment and assessment plan dated January 14, 2015.

Result:

The applicant is not entitled to the medical benefits claimed because they are not reasonable and necessary as a result of the accident.

The applicant struck a left-turning vehicle on the front passenger side on the evening of November 30, 2012. There is no dispute that the applicant went to hospital following the accident and was diagnosed with bruising to the chest and possibly to the kidney, and soft tissue injuries WAD I, sprain/strain of the thoracolumbar spine and later developed a small disc herniation of the L5-S1 with an impingement of the left S1 nerve root origin. There is also no dispute that the applicant developed psychological symptoms after the accident and that psychological counselling was recommended and paid for by Allstate.

At issue is whether the psychological treatment claimed in the two disputed treatment plans is necessary and reasonable as a result of the accident. Under the Schedule, an insurer is only liable to pay for medical benefits that meet these criteria. An insured must prove on a balance of probabilities that the medical benefits, the treatment and assessment plans in this matter, are reasonable and necessary.

The Arbitrator reviewed all the evidence submitted including the four treatment plans for psychological treatment. The applicant submits that Allstate should pay for the two disputed plans because they are recommended by the treatment provider that because the applicant continues to suffer from pain and psychological impairment, and because the applicant has not returned to work.

Allstate argues that the disputed treatment plans are not reasonable or necessary.

The onus is on the applicant to prove that the disputed plans are reasonable and necessary.

Having reviewed all the evidence, the Arbitrator found the applicant is not entitled to the medical benefits claimed because the applicant failed to demonstrate that, on a balance of probabilities, the treatments in dispute are reasonable and necessary.

Deutschmann Law serves South-Western Ontario with offices in Kitchener-Waterloo, Cambridge, Woodstock, Brantford, Stratford and Ayr. The law practice of Robert Deutschmann focuses almost exclusively in personal injury and disability insurance matters. For more information, please visit www.deutschmannlaw.com or call us toll-free at 1-866-414-4878.

It is important that you review your accident benefit file with one of our experienced personal injury / car accident lawyers to ensure that you obtain access to all your benefits which include, but are limited to, things like physiotherapy, income replacement benefits, vocational retraining and home modifications.

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